BSW First Practicum Application Form

University of Missouri-St. Louis

School of Social Work

Semester for which Practicum is being requested

Year 20_____Fall Spring Summer

(Circle One)

Faculty Advisor ______

BSW Program Status:

______Fully admitted to BSW: Semester/Year ______

______Provisional admit: Applied Semester/Year ______

IF YOU ARE PRE-SOCIAL WORK & HAVE NOT YET APPLIED TO THE BSW PROGRAM, YOU ARE NOT ELIGIBLE TO APPLY FOR PRACTICUM AT THIS TIME

In addition to a BSW, I am pursuing a certificate in: □ Gender Studies □CAST

Did you complete a practicum/internship for your Associate’s Degree? □Yes □No

If yes, what is the name of the agency: ______

  1. Personal Data:

Name ______Student # ______

Home Address ______/______/ ______

Street City/State Zip

Email address: ______

Phone numbers: Cell: ______Home: ______

Expected Date of Graduation ______

Minor ______

Person to notify in an emergency ______

Phone # and email: ______

II Academic Pre-requisites:

You must have 90 hours of course work including math competency completed and a minimum GPA of 2.5 in social work and related areas andto be eligible for practicum.

Indicate the number of hours that will be completed at the end of the current semester:______

Current BSW GPA: ______

Math course number: ______Completed (yes/no/IP) ______Grade ______Semester taken ______

The following is a list of courses required to receive a BSW. Check all those that are completed or are in the process of completion.

  1. Professional Foundation Courses:

Course Number / Completed (Yes/No) / Grade / Semester
Taken
SW 2000 or equivalent if taken at STLCC
SW 2200 or equivalent if taken at STLCC
SW 2001 or equivalent if taken at STLCC
SW 3100
SW 3210
SW 3510
SW 3700
SW 4110
SW 4300
SW 4350 (if applicable)
  1. Area Requirements:

Course Number / Completed (Yes/No) / Grade / Semester
Taken
BIOL (Please indicate course number)
SOC 1010
PSYCH 1003
ECON 1000 or Econ 1005
POL SCI 1100
SOC/PSYCH 2160

Statistics Requirement (Only one course should be selected in this area)

Course Number / Completed (Yes/No) / Grade / Semester
Taken
SOC 3220
CCJ 2220
PSYCH 2201
If other please indicate course information below

Research Requirement (Only one course should be selected in this area)

Course Number / Completed (Yes/No) / Grade / Semester
Taken
SOC 3230
SW 3410
CCJ 2210
PSYCH 2219
If other please indicate course information below
  1. General Education Requirements (for the University):

____ Three Humanities Courses

____ Four Natural Sciences or Mathematics Courses or a combination of the two totaling

12 credit hours.

____ Cultural Diversity

____ Math Proficiency (Math 1030 or 1020)

____ Freshmen Composition English 1100 or equivalent

____ Advanced Expository Writing Junior Level English 3100

____ American History and Government Requirement

III. Practicum Information

Social Problems/Target Populations in which you are interested:

Career Plans:

Agency Preferences:

Name of agency, address, phone number and contact person:

  1. ______

______

  1. ______
  1. ______

______

  1. ______

______

  1. ______

______

Student Signature: ______

Date Submitted: ______

Faculty Advisor’s Signature: ______

Date Signed: ______

Agency(s) Approved:A B C D E

Date Approved: ______

Assistant Director of Field Education Signature: ______

1